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JEMCR 2016; 1; 17-9
DOI: 10.5152/jaemcr.2015.1251
Could Propafenone hydrochloride Cause Visual
Hallucination?
Tanzer Korkmaz1, Nihat Pekel2, Süveyda Yeşilaras1, Deniz Oray1, Cem Ertan1
Department of Emergency, İzmir University Faculty of Medicine, İzmir, Turkey
Department of Cardiology, İzmir University Faculty of Medicine, İzmir, Turkey
1
2
ABSTRACT
Introduction: There may be some cardiac and non-cardiac side effects of propafenone hydrochloride, which is a class IC antiarrhythmic agent
used for medical cardioversion in atrial fibrillation and atrial flutter.
Case Report: Propafenone hydrochloride (600 mg) was orally administered to a 74-year-old patient with tachycardia due to new-onset atrial
fibrillation with rapid ventricular response. After 30 min, sinus bradycardia in response to atropine, swelling and numbness in the tongue, slurred
speech, blurred vision, diplopia, spasm and contradiction at the right arm and leg, drowsiness, and visual hallucinations lasting for 24 h developed.
The patient recovered without any sequel and was discharged from the coronary intensive care unit.
Conclusion: Although propafenone hydrochloride is known to be safe at therapeutic doses, various possible multiple side effects
should be considered.
Keywords: Propafenone HCl, side effect, hallucinations, emergency service
Received: 24.06.2015 Accepted: 17.08.2015
Introduction
Propafenone hydrochloride (HCI) is a class IC antiarrhythmic agent used for medical cardioversion in atrial fibrillation, atrial
flutter, and paroxysmal supraventricular tachycardia (PSVT) (1). It slows down nerve conduction through the direct stabilization of the myocardial membrane via Na channel blockage (which increases the atrioventricular nodal refractory period). In
addition to its action of directly slowing innervation of the heart tissue, it also has some calcium-channel and beta-receptor
blocking effects. These properties make propafenone HCl an effective converting agent for up to 40%–70% of patients with
atrial flutter and fibrillation (2). It directly works on the heart tissue and slows the nerve impulses to keep the heart rhythm
normal. Compared with other class IC agents, propafenone HCl has a lower observed prodysrhythmic rate in therapeutic
doses. In a review, it was stated that a single 600 mg dose of propafenone HCl is considered to be effective and safe to
convert AF rhythm to sinus rhythm (3). The most common side effects include conduction disturbances on an electrocardiogram (ECG), blurred vision, dysgeusia, and dizziness. Other side effects mostly include non-cardiac effects such as nausea/
vomiting, dry mouth, constipation, dyspepsia, fatigue, tinnitus, palpitations, abdominal pain, fever, vision abnormalities, and
unusual dreams (4). Here, we report this case because of the coexistence of both frequent cardiovascular and rare noncardiac side effects after the administration of a single dose of propafenone HCl.
Case Report
A 74-year-old female patient with a history of hypertension presented to the emergency department with a complaint of palpitation. She denied any chest pain or light-headedness and had no history of prior palpitations, diabetes, and angina or myocardial
infarction. She was on 100 mg aspirin, 150 mg dabigatran eteksilat, 50 mg metoprolol, and 160/12.5 mg hidroklorotiazid valsartan.
On examination, she was alert, oriented, and cooperative; had a Glasgow Coma Scale score of 15; and an oxygen saturation of 99%.
Her pulse was irregular at 158 beats/min. Her blood pressure was 153/95 mmHg, her respiratory rate was 20 breaths/min, and she
was afebrile. Her lungs were clear to auscultation, and she had no murmurs or extra heart sounds. After the patient was monitorThis study was presented at 4th Mediterranean Emergency Medicine Congress (MEMC) - Global Research on Acute Conditions Team
(GREAT) 5-9 September 2015, Rome, Italy.
Address for Correspondence:
Tanzer Korkmaz, Department of Emergency, İzmir University Faculty of Medicine, İzmir, Turkey
E-mail: [email protected]
©Copyright 2016 by Emergency Physicians Association of Turkey - Available online at www.jemcr.org
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JEMCR 2016; 1; 17-9
Korkmaz et al.
Side Effects of Propafenone Hydrochloride; Case Report
Figure 1. ECG findings revealed AF with rapid ventricular response
ized, an ECG was taken, and she was diagnosed to have AF with a rapid ventricular response (Figure 1). Diltiazem (25 mg) was intravenously
administered for rate control. Pulse rate decreased to 100 beats/min,
but it continued irregularly, and her complaints of palpitation continued. Her blood pressure dropped to 70/40 mmHg. Cardiology consultation was requested for new-onset AF. Peroral propafenone HCl
(600 mg) was given to the patient for rhythm control, and possible
cardioversion was conducted following echocardiography examination. Conversion to sinus rhythm was achieved an hour after the administration of propafenone HCl (Figure 2). After 30 min, short-term
sinus pause (<10 s) and two symptomatic sinus bradycardia periods
with 30-min intervals (pulse rate: 30 beats/min) occurred. The level of
consciousness and general condition of the patient improved, and
pulse rate reached to a level of 70–80 beats/min following the consecutive intravenous administration of 1 mg atropine twice in sequence.
Troponin I value was within the normal range. After 2 h, swelling and
numbness in the tongue, slurred speech, blurred vision, and diplopia
developed. The patient stated that there were spasms and contractions,
particularly in the right arm and leg. In simultaneous measurements,
blood glucose level was 116 mg/dL, sinus rhythm was detected on
ECG, and no neurologic deficit was determined. No electrolyte disturbances were determined in the laboratory workup. Meanwhile, drowsiness increased and visual hallucinations and hand movements as if
she was pointing out to something emerged. When the patient was
questioned about the gestures, she explained that a girl who she has
supposedly met previously but has no recollection of her name came
up and then another man and woman brought flowers and that she
was trying to reach the flowers. Because of the continuation of visual
hallucinations, diffusion magnetic resonance imaging was performed,
and it revealed no pathological findings. All findings were considered to
be side effects related to propafenone HCI, and cardiology consultation
was repeated and then the patient was hospitalized to the intensive
care unit for follow-up. All side effects disappeared after 18 h, and the
patient was discharged after 2 days.
Discussion
Rhythm control is recommended for the patients who are ≤65 years
old, those with new-onset AF, those without heart failure and who
have not experienced heart failure under previous antiarrhythmic
drug use, and in patients who demand rhythm control (5).
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Figure 2. Conversion to sinus rhythm was achieved with propafenone HCl
Dronedarone, flecainide, propafenone, or sotalol may be used in
patients without structural defects to control rhythm and to maintain sinus rhythm. Only amiodarone is recommended in patients
with an ejection fraction lower than 35. Left ventricular dysfunction and deterioration of congestive heart failure may occur because of beta-blocker and dose-dependent negative inotropic effects of propafenone HCl on the myocardium (5). Because there
were no described heart failure or physical examination findings
of our patient and she was not under any antiarrhythmic agents
and had new-onset AF, propafenone HCl was preferred for rhythm
conversion. Although the side effects of propafenone HCl are dose
dependent, its cardiac toxic effects may cause hypotension, ventricular dysrhythmias, and sudden death in therapeutic doses (6).
Koppel et al. (6) reported that class IC agents cause bradyarrhythmias in two-thirds of the patients. Symptomatic sinus bradycardia
responding to atropine developed twice in our case. Although
propafenone HCl itself may solely cause bradycardia, this adverse
effect may have also emerged as a result of propafenone HCl’s interaction with metoprolol, which has been used by the patient for
a long period of time (7).
In therapeutic doses, propafenone HCl may cause non-cardiac and
cardiac toxicities. Non-cardiac adverse effects include cholestatic
hepatitis, reactive airway disease, agranulocytosis, hemolysis, drug
fever, and ataxia (3). Torres et al. (8) reported that a serious dyspnea
occurred in a 78-year-old case when the second dose was applied at
the first day of treatment; however, this did not occur in our patient.
Central nervous system side effects of propafenone HCl are generally dose dependent, and the mechanism of this effect is not
completely understood. Sleep disturbances, depression, lethargy, hallucination, delirium, and paranoia may occur because of
beta-adrenergic receptor blockage. Pfeffer et al. (9) reported that
propafenone HCl may cause organic psychosis in patients who
use venlafaxine because of increased venlafaxine serum levels. Because there is no antipsychotic and similar drug history in our case,
hallucinations are believed to be related to propafenone use in
therapeutic doses. There is no a standard antidote for the overdose
Korkmaz et al.
JEMCR 2016; 1; 17-9
Side Effects of Propafenone Hydrochloride; Case Report
of propafenone HCl. Brubacher et al. reported that hypertonic sodium bicarbonate treatment was efficiently used for a patient with
wide QRS complex tachycardia related to propafenone administration in a therapeutic dose (450 mg) (3). Bayram et al. (10) reported
that a patient who had cardiac arrest following the IV administration od propofenone HCL, recovered with high dose IV insulin. No
additional medication other than atropine was administered to
our case because no life-threatening cardiac effects were present,
and sinus bradycardia responded to atropine.
Although the administration of propafenone HCl in therapeutic doses
at an emergency department is considered safe, it should be considered that even a single and first dose may cause one or more side
effects.
Ethics Committee Approval: Ethical committee approval was not deemed
necessary.
Informed Consent: Written informed consent was obtained from patient
who participated in this study.
Peer-review: Externally peer-reviewed.
Author contributions: Concept -T.K.; Design - T.K., S.Y., D.O.; Supervision - T.K.,
N.P., S.Y., D.O. C.E.; Resource - T.K.; Materials - T.K., S.Y.; Data Collection and/or
Processing - T.K., N.P., S.Y., D.O.C.E.; Analysis and/or Interpretation - T.K., N.P.;
Literature Search -T.K., N.P., S.Y., D.O.C.E.; Writing - T.K., N.P., S.Y., D.O.C.E.; Critical
Reviews - T.K., N.P., S.Y., D.O. C.E.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study has received no
financial support.
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